Joint Strategic Needs Assessment

• The number of older people ( mainly age 80+) entering residential care has risen in 09 after two years of falling admissions, the reasons for this needs to be understood and preventative and early intervention services put in place to re-establish a reduction in admissions
• There are a low number of high quality care homes in the city
• There are a high level of unplanned hospital admissions from care homes
• Medicines management in care homes presents a significant risk. A recent audit carried out by NHS Nottingham City in 80 care homes across the city identified significant variation in the frequency and quality of medication reviews, a lack of formal communication links between care home staff, GPs and community pharmacists and other services, high levels of ‘waste’ medicines, a lack of formal training and policies around essential medicines management activities e.g.: Administration of medicines and controlled drugs management which are increasing risk of harm to both patients and staff, a lack of coordination of the prescribing of other agencies including OOH providers, secondary care providers, community psychiatric teams and dieticians in order to minimise conflict and duplication, and a need to improve systems for the safer management of controlled drugs.
• There is a need for an ongoing process of monitoring, review and provision of support to facilitate technical, clinical and operational medicines management processes in care homes in NHS Nottingham City.
• There has been an overprovision of older persons sheltered accommodation in the city however the take up has increased in 2008. This oversupply is not evenly distributed across the city.
• There is evidence that Extracare provision is a cost effective preventative service with good outcomes for older people.  The demand across the city for Extracare housing outstrips supply with waiting lists for schemes in the city
• A number of older people with long term conditions and complex needs with a high risk of hospital admission may not be accessing social care services 
• The current intermediate care service operates to full capacity most of the time.  This service may well be filling the gap in appropriate assessment and recuperation services. 
• There are a significant number of people who have been identified through the population stratification process as likely to benefit from the case management/community matron service but are not currently receiving it 
• There is an ongoing need for training and education on falls risk assessment and post-stroke care
• For many older people the experience of health and social care system is fragmented and uncoordinated with too many “hand-overs”

• Establish a Nottingham City joint strategic commissioning group to facilitate joint  planning decisions together with clear governance arrangements
• Focus on the development of joint commissioning intentions that deliver on prevention and early intervention outcomes
• Commission more flexible forms of older persons supported accommodation including increased Extracare capacity.  A rationalisation and reduction of stock is required and investment made in a range of housing options for older people that includes sheltered options
• Commission services that promote personalisation and enable users and carers to feel supported and make informed choices through self-directed support options where possible
• Commission integrated front line services working together to achieve better outcomes for older people and people with long term conditions, including helping them to stay in their own homes for longer
• Complete the joint review of the role and capacity of intermediate care, refocusing on prevention of avoidable admission to hospital or long term care through the enhancement of the crisis response element
• Review the community matron model and ensure case management services are better utilised and targeted at those most in need
• The PCT must work with GPs, community pharmacists and social care partners to determine how medication errors in care homes for older people can be reduced as per Department of Health safety alert (2010)001
• PCTs with primary medical care contractors, providers of pharmaceutical services and social care partners should review the safety of local prescribing, dispensing, administration, and monitoring arrangements in the provision of medication to older people in care homes and to establish an action plan for effective joint working in the future, including auditing on-going progress.
• Sustainable expert specialist medicines management support and advice to care homes and commissioners is required at strategic, clinical and technical/operational level in order for the PCT to meet the requirements of the DH safety alert and to implement the recommendations of the CHUMS report.
• High standards of medicines management covering the prescribing, dispensing, administration and monitoring of medicines use in care homes setting need to be built into contracts and service specifications through the commissioning process and close working between PCT commissioners and the medicines management team will be required.
• Commissioning decisions should include consideration of how best to ensure regular, robust clinical review and monitoring of medication whether by GPs or pharmacists. Any existing services or specifications relating to care of patients in the care homes setting should be reviewed to ensure all aspects of medicines management are covered as per the safety alert.

Complex intensive health and social care needs in the elderly and people with long term conditions are driven by the following fixed and modifiable risk factors:-

• Age
• Ethnicity
• High levels of deprivation
• Low educational attainment
• Unhealthy lifestyles (high smoking, poor diet, low physical activity)

In addition:

• As people grow older, their health needs become more complex with physical and mental health needs frequently being inter-related and impacting on each other
  
• Many older people receive multiple types of medication.  Any medication has the potential to cause adverse effects as well as benefits.  Any new or changed treatment to help a physical condition can lead to, or worsen, mental health problems.  Similarly, treatment for mental health problems can adversely affect physical health in vulnerable older people
• Older people prescribed neuroleptic medicines (drugs used to treat mental disorders but also to subdue patients) are particularly prone to side-effects, such as a greater risk of falls and hip fractures (Oborne et al 2002)
• The Care Homes Use of Medicines Study (Barber et al 2009) has found that the average care home resident has a mean age of 85 and is taking an average of 8 medicines, and on any day 7 out of 10 patients will experience at least one medication error which puts them at risk of harm.
• Physical health difficulties can both contribute to and be compounded by depression and anxiety, as well as acute and chronic confusion.  Conditions associated with chronic pain, and those leading to the loss of independence, bereavement and possibly the loss of the family home if a move is necessary, are commonly associated with depression
• Both physical and mental health difficulties can affect an individual’s ability to care for themselves independently and potentially have major implications for their way of life. For example, surveys indicate that 25% of people receiving home care services are depressed
• A person’s ability to look after their own health, by taking a good diet, keeping active both mentally and physically, managing medication correctly and co-operating with treatment, can be adversely affected by depression or confusional states, such as dementia
• People with diagnosable physical illnesses, especially chronic or recurrent conditions commonly show higher rates of mental health problems than the general population. Recovery from or the management of, for example diabetes and coronary heart disease can be compromised as a consequence of mental health problems, especially depression. (DH 2003)
• Rates of depression in severe and chronic diseases can be high. It has been shown that up to 60 % of people who have suffered a stroke can be depressed, up to 40 % of people with coronary heart disease, cancer, Parkinson’s Disease and Alzheimer’s can also be suffering from a depression
• Depression in late life was an independent risk factor for heart failure among elderly women in another study (Williams et al., 2002)
• Review evidence suggests that depression increases mortality and morbidity in ischaemic heart disease (Roose, Glassman and Seidman (2001)

Current government figures estimate there to be 34,800 over 65s living in the City of Nottingham, (Source: Poppi)with 38,008 over 65s registered with NHS Nottingham City’s GPs.  Of these, 18,165 are thought to have a long term condition, 10,000 of these people are likely to be living alone.

48.9% of the city’s people of pensionable age receive at least one other state benefit on top of the state pension.

In the short to medium term, the City is unlikely to follow the national trends of increasing numbers of people over retirement age, although the number aged 85+ is projected to increase to 500 additional people to 2015 , due to improved survival rates in that age-group, particularly amongst men. Over 65s currently form 11.66% of the total population of the city – this will fall slightly to 11.33% in 2015.

It is estimated that there are currently 18,165 over 65s with limiting long-term conditions - 10,000 of these will live alone.

Figure 1: Estimated population in Nottingham City aged 65+ with LLTI (Source: poppi.org.uk)

Age band	Population	Number with LLTI	% with LLTI
65 – 74 years old	17,000	7,930	47%
75 – 84 years old	12,900	7,260	56%
85 years plus	5,000	3,020	60%

The main users of health services are people aged 65+ (‘older people’).  Over 80% of people aged 70+ suffer from a significant (i.e. in need of treatment) physical illness (Rossman, 1979).  At any one time in the UK older people occupy around two-thirds of hospital beds (Department of Health, 2001).

People with long-term conditions frequently have more than one condition.  Around half of this population will have more than one major health problem and around a quarter will have three or more problems (British Household Panel Survey 2001), with the chances of having more than one problem increasing with age.

At 31 March 2007, 225 over 65s were registered as being deaf (60 aged 65-74; 165 aged 75+), whilst 550 over 65s were registered as being hard of hearing (85 aged 65-74 and 465 aged 75+). An estimated 3,600 people are registered blind or partially sighted and around 18,200 have a limiting long-term illness.

Not surprisingly, the percentage with an LLTI rises with age.  Amongst older people, the percentage with an LLTI rises from 32.8% of people in their 50s to 66.9% of those aged 80 and over.  In all age groups under aged 80, the percentage amongst men is slightly higher than amongst women.  A higher rate for women aged 80+ may be because they have an older age profile than men in the age group.

The top 1% of the population at highest risk consists of 3,182 patients of whom 84% were aged 65 or above.  Over 50% of this group are female which is expected as 60% of the over 65 population in Nottingham is female.  70% of adult social care clients are aged over 65. 

Geographic comparison at super output area of the numbers of people in the 1% highest risk of hospital admission category and those supported by social care illustrates corresponding high levels of provision in areas with high level of need, as defined by high risk of admission (see below).  However comparison of rates (per 1,000 people aged over 65) of service provision and need shows less good correlation.  Further analysis of data is required including Mosaic profiling to investigate potential differences in need and provision of services. 

Figure 2: Distribution of population with                  Figure 3: distribution of Social Care Clients (‘Older high risk of hospital admission                                 people’                                      

Care home residents
Medicines management in care homes presents a significant risk. A recent audit carried out by NHS Nottingham City in 80 care homes across the city identified significant variation in the frequency and quality of medication reviews with care home residents, a lack of formal communication links between care home staff, GPs and community pharmacists and other services, high levels of ‘waste’ medicines, a lack of formal training and policies around essential medicines management activities e.g.: Administration of medicines and controlled drugs management which are increasing risk of harm to both patients and staff, a lack of coordination of the prescribing of other agencies including OOH providers, secondary care providers, community psychiatric teams and dieticians in order to minimise conflict and duplication, and a need to improve systems for the safer management of controlled drugs.

The Care Homes Use of Medicines Study (Barber et al 2009) has found that the average care home resident has a mean age of 85 and is taking an average of 8 medicines, and on any day 7 out of 10 patients will experience at least one medication error which puts them at significant risk of harm.

Carers
Older carers form a significant group in Nottingham.  Those older people providing unpaid care are estimated at 3,639 currently and that number projected to rise to 3.838 in 2020.  Of the current group of older carers it is estimated that 178 are aged over 85. There is a separate Carers chapter in the JSNA which considers the topic in more detail.

Figure 4: The model below illustrates the range of current Prevention and Early Intervention Services for older people available in Nottingham City

Figure 5: Health & Social Care Service Use for Older People Nottingham City 2008-09 for services commissioned by NHS Nottingham City and Nottingham City Council (not including dementia services).

Service Type	Description of Service	Number of Users 08-09
Sheltered Housing	Range of Sheltered Housing Providers	2768
Extracare Housing	4 provider sites providing stepped care to tenants/owners	121
Care alarms	Pendant alarms and similar IT to older persons	3385
Floating Support	Housing related support to older people through a commissioned service	260
3rd Sector support	Kindred Spirits Over 65s	320
3rd Sector day centre	Age Concern Sybil Levin	31
3rd sector Advice & Support	Age Concern Central service	2,250
3rd Sector Support	Sherwood stroke club	27
3rd Sector preventative	Hospice At home Service	700
3rd sector BME support	Asian Women’s Service. Support and lunch club for older Muslim Asian women	60
3rd Sector Day centre	Radford Care Group. Lunch clubs, range of support and health and well being services	42
3rd Sector Lunch club	Nottingham Carewatch	81
Purchased Elderly/EMI Nursing Home Care	Range of Private Sector Provider Homes	208
Purchased Elderly/EMI Residential Care	Range of Private Sector Residential Homes	599
Local Authority Care Homes	4 Care Homes	404
Local authority Homecare	In House Intake and Reablement	1068
Local authority Homecare	NEHCS Through the Night service	383
Direct Payments	Over 65s Direct Payments	129
Local authority Day care	Over 65s Generic Day Care. 7 centres.	389
Local Authority BME day care	Marcus Garvey Centre	46
Local Authority BME day care	Indian Day Centre	37
Local Authority BME Day Care	Pakistan Day centre	14
3rd Sector Commissioned Advocacy	Age Concern Advocacy	47
Local authority commissioned Telecare	Range of assistive Technology packages	576
	TOTAL OLDER PEOPLE PACKAGES OF SOCIAL CARE DELIVERED	13,945
Jointly commissioned Intermediate Care (including specialist mental health intermediate care service)	Intensive time- limited rehabilitation and re-ablement service (38 bed-based places and 100 places at home  any one time)	1000
Long term conditions teams (Community Matrons, heart failure nurse, COPD nurses)	Highly skilled team of approximately 30 wte supporting people with long term conditions  and complex needs, around 80% of which are aged 65 and over.  Includes the use of TeleHealth monitoring equipment.	788
Specialist Falls Prevention Service	Highly specialist team providing evidence based interventions to prevent falls (including postural stability classes)	794
Domiciliary Nursing and Rehabilitation Service	Rehab service providing first line falls assessment and intervention and other rehabilitation	756
Third Sector hospital discharge support	Home from hospital support (Age Concern and British Red Cross)	7163

 

Figure 6: The model below illustrates the proposed service model for integrated care services for older people in Nottingham City.  This model is in the early stages of implementation.

In 2009 Nottingham City ASH commissioned an independent needs modelling for current and future supported housing options across a range of client groups including frail elderly, dementia and generic older persons support. This needs modelling provides indicative at risk populations and suggested target numbers for older people to receive a service. Provisional modelling indicates that for Nottingham 14,180 older people will need housing related services, 1,714 will need accommodation based services, 441 non-accommodation services, 343 people will need community alarms, 2.400 people will need home improvement agency
(for detailed results see HGO Consultancy Needs Modelling Nottingham City 2009/10)

Estimated figures are also available which apply survey data to ONS population projections to give an idea of likely need for services in the future. These are given in figures 7 and 8.

Figure 7: Projected Older People in Nottingham unable to manage at least one domestic task on their own (Source: poppi.org.uk)

		2009	2015	2020	2020	2025
People aged 65-74...	...unable to manage at least one domestic task on their own	4,080	4,056	4,344	4,512	4,704
People aged 75+...		8,592	8,448	8,352	8,592	9,504
Total over 65s		14,778	14.946	12,696	15,523	18,191

Figure 8: Health Related Needs Projections for Nottingham

Health Condition	2009	2015	2020	2025	2030
Over 65s with LTC caused by emphysema/bronchitis	579	603	626	666	735
Over 65s with LTC caused by heart attack	1,699	1,759	1,819	1,937	2,131
Over 65s with a LTC caused by stroke	801	833	866	930	1,022
Over 65s unable to manage at least one self care activity on their own	12,089	12,286	12,745	13,588	14,937

Source poppi.org.uk

Department of Health (2001) National Service Framework for Older People
Local Government Association (2003) All our tomorrows: inverting the triangle of care
Department of Health (2005) National Service Framework for Long Term Conditions
Department of Health (2006) A New Ambition for Old Age: Next Steps in Implementing the National Service Framework for Older People
Department of Health (2006) Our Health, Our Care, Our Say
Wigan Time Limited Contact & Support Service www.dhcarenetworks.org.uk
Personal Social Services Research Unit for Department of Health (2010) National Evaluation of Partnerships for Older People Projects (POPPS): final report.
Ipsos MORI for Department of Health (2009) Long Term Conditions Research Study

User and carer views have been extensively canvassed for the 2008 Nottingham City council Older Persons Strategy and in 2009 for the Older Persons Mental Health Day services Review, together with the current 2009 consultation on the joint Commissioning Strategy for Dementia. In addition older persons views have been sought on defined topics for example the Extracare review of charging arrangements 2009.  
The long term conditions research study carried out by Ipsos MORI for DH (2009) has shown the following views on Long Term conditions and self care, and on seeking self care advice:
Long Term Conditions and Self Care
Two in five English adults say they have a long term health condition, a finding consistent with the 2007 survey. Two thirds of these people feel that they receive some or all of the support they require, with a further one in five feeling that no support is necessary. Nearly four in five say they play an active role in treating their condition, also in line with our findings from 2007.

Positively, the majority of adults with a long term health condition say they are comfortable taking responsibility for the care of their condition, as in 2007 and, notably, there is a significant increase in those saying that they are very comfortable doing so compared to 2007 (up by 5 percentage points).

Non-white people and those in London are less likely to feel comfortable taking responsibility for their condition, suggesting that they may benefit from extra support.

People typically mention more information about their condition and treatment as potentially helping them take a greater role in the care of their condition. Notably, there are fewer people than in 2007 who are unable to say what would help.

Awareness and usage of training courses which may help individuals to learn the skills that would help them care for their condition are low. Two thirds of adults with a long term health

Seeking Self Care Advice
As in the previous wave, two in five adults with a long term health condition say they have not approached any person or organisations for advice on self-care or information on their long term health condition. However, again as in 2007, the preferred source of information and advice is the family doctor, which may be expected since previous Ipsos MORI research shows they are among the most trusted professionals in society.

Those who have asked for advice are highly satisfied with the service they receive, with very few people expressing any dissatisfaction. Encouragingly, almost all people say that the advice helped them play a more active role in dealing with their long term condition.

Awareness of the information and advice that can be offered by pharmacies has increased by 11 percentage points since 2007.

Around half of people have discussed managing their health and care needs with a doctor or nurse in the past 6 months and most of these have agreed a plan. Almost all of these people, furthermore, feel that the discussion has improved the care they receive.

NHS Nottingham City and Nottingham City Council Adult Support and Health are incorporating equality impact into the ongoing development of their draft older people’s joint commissioning strategy and will complete a full EIA on completion and consultation on the strategy in April 2010.

• The number of older people ( mainly age 80+) entering residential care has risen in 09 after two years of falling admissions, the reasons for this needs to be understood and preventative and early intervention services put in place to re-establish a reduction in admissions
• There is a low number of high quality care homes in the city
• There are a  high level of unplanned hospital admissions from care homes
• Medicines management in care homes presents a significant risk.
• There has been an overprovision of older persons sheltered accommodation in the city however the take up has increased in 2008. This oversupply is not evenly distributed across the city.

• There is evidence that Extracare provision is a cost effective preventative service with good outcomes for older people.  The demand across the city for Extracare housing outstrips supply with waiting lists for schemes in the city
• A number of older people with long term conditions and complex needs with a high risk of hospital admission may not be accessing social care services 

• The current intermediate care service operates to full capacity most of the time.  This service may well be filling the gap in appropriate assessment and recuperation services. 
• There are a significant number of people who have been identified through the population stratification process as likely to benefit from the case management/community matron service but are not currently receiving it 
• There is an ongoing need for training and education on falls risk assessment and post-stroke care
• For many older people the experience of health and social care system is fragmented and uncoordinated with too many “hand-overs”

• Establish a Nottingham City joint strategic commissioning group to facilitate joint  planning decisions together with clear governance arrangements
• Focus on the development of joint commissioning intentions that deliver on prevention and early intervention outcomes
• Commission more flexible forms of older persons supported accommodation including increased Extracare capacity.  A rationalisation and reduction of stock is required
• Commission services that promote personalisation and enable carers to feel supported and make informed choices through self-directed support options where possible
• Commission integrated front line services working together to achieve better outcomes for older people and people with long term conditions, including helping them to stay in their own homes for longer
• Complete the joint review of the role and capacity of intermediate care, refocusing on prevention of avoidable admission to hospital or long term care through the enhancement of the crisis response element
• Review the community matron model and ensure case management services are better utilised and targeted at those most in need
• Build older persons involvement in strategic planning and commissioning

• The number of older people ( mainly age 80+) entering residential care has risen in 09 after two years of falling admissions, the reasons for this needs to be understood
• Further research required to assess equality of access for reablement and care at home services those at highest risk of hospital admission
• Further Research into local health and support needs of BME groups of older people with LLTI
• Further analysis of data is required including Mosaic profiling to investigate potential differences in need and provision of services
• There needs to be Improved sharing of primary care and social care data on individuals with long term conditions and complex needs to inform predictive modeling
• There needs to be  an improved understanding of the contribution of mental health to the burden of life limiting illness

Shirley Smith, Assistant Director of Commissioning, Community Services, NHS Nottingham City, Shirley.smith@nottinghamcity.nhs.uk
Jo Williams, Commissioning Manager, NHS Nottingham City, joanne.williams@nottinghamcity.nhs.uk

Rod Madocks, Commissioning Officer (Older Persons), Adult support & Health, Nottingham City Council, rod.maddocks@nottinghamcity.gov.uk

Care Service Efficiency Delivery (2009) Projecting Older People Population Information System (POPPI) Available at http://www.poppi.org.uk/ [Accessed 08 January 2010]
Department of Health (2008)Raising the Profile of Long Term Conditions Care: A Compendium of Information. Available at http://www.dh.gov.uk/dr_consum_dh/idcplg?IdcService=SS_GET_PAGE&ssDocName=DH_062820 [Accessed 08 January 2010]
Department of Health (2006) A New Ambition for Old Age: Next Steps in Implementing the National Service Framework for Older People. Available at http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4133947.pdf [Accessed 08 January 2010]
Department of Health (2006) Our Health, Our Care, Our Say. Available at http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4127459.pdf [Accessed 08 January 2010]
Department of Health (2005) National Service Framework for Long Term Conditions. Available at http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4105369.pdf [Accessed 08 January 2010]
Department of Health (2001). National Service Framework for Older People. Available at http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4071283.pdf [Accessed 08 January 2010]
Ipsos MORI for Department of Health (2009) Self Care and Long Term Conditions Survey. Available at http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_101092.pdf [Accessed 08 January 2010]
Local Government Association (2003) All our tomorrows: inverting the triangle of care. Available at http://www.lga.gov.uk/lga/publications/publication-display.do?id=21169 [Accessed 08 January 2010]
Oborne C.A., Hooper R., Li K.C., Swift C.G. and Jackson S.H.D. (2002) An indicator of appropriate neuroleptic prescribing in nursing homes. Age and Ageing 31: 435-439. Available at http://ageing.oxfordjournals.org/cgi/reprint/31/6/435.pdf [Accessed 08 January 2010]
Office for National Statistics (2002) Living in Britain 2001. Available at www.statistics.gov.uk/lib2001/index.html [Accessed 08 January 2010]
Personal Social Services Research Unit for Department of Health (2010) National Evaluation of Partnerships for Older People Projects: final report. Available at http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111353.pdf
Romanelli, J, Fauerbach, J., Bush, D. and Ziegelstein, R. The Significance of Depression in Older Patients after Myocardial Infarction. Journal of American Geriatric Society 50:817-822
Roose, S.P., Glassman, A.H. and Seidman S.N (2001) The Relationship Between Depression and other Medical Illnesses, Journal of American Medical Association 286:1687-1690
Williams, A.S., Stanislav, V., Kasl, S.V., Heiat, A., Abramson, J.L., Krumholz, H.M. and Vaccarino V (2002). Depression and risk of heart failure among the elderly: a prospective community-based study. Psychosomatic Medicine 64:6-12 (2002) Available at http://www.psychosomaticmedicine.org/cgi/content/abstract/64/1/6 [Accessed 12 February 2010]